Welcome everyone to our crosstalk that is part of the SCCM 2022. My name is Abhishek Parthwaj and I'm a third year pulmonary and critical care medicine fellow at the Cleveland Clinic. Today I have with me Dr. Farrington and Dr. Moses who will be discussing a very important and relevant topic in the ongoing pandemic, the moral distress that this pandemic has caused for healthcare professionals and the impact that this particular pandemic has on the lives of everyone involved, including the healthcare professionals and the people. So Dr. Farrington, we'll start with you. Please tell us your background and how are you so passionate about this? Okay, thank you for the introduction. My name is Elizabeth Farrington. I've been a pediatric critical care pharmacist for about 30 years, bachelor's of science at the University of North Carolina PharmD University of Kentucky and I also did my residency there. And then was at the University of North Carolina for about 17 years, but moved to the coast about 10 years ago to work here at New Hanover Regional Medical Center, which is in Wilmington, North Carolina. I love taking care of children. And during this pandemic, we have had so many nurses leaving to go stay at home with their kids. I mean, the shortage of nurses is really making it a struggle to take care of our patients. That's right. Well, thanks for sharing. Dr. Moses. Thank you so much for the introduction. I'm very excited to be here with you both today as part of this year's Society of Critical Care Medicine Congress. My name is Benjamin Moses. I am an anesthesiologist and intensivist. I work in surgical critical care at the University of Virginia. I served in the United States Army for 10 years. I've worked in military facilities, VA health facilities, private hospitals, and academic centers. And what I've seen over the course of my career, my last about 20 years since I started my journey in medicine has been an increasing awareness of moral distress in general, and also especially moral distress in physicians. It's been described for a long time in our nursing community as an issue that practitioners face, but more and more it's being identified as an important and critical factor of the durability of practice for physicians, for pharmacists, for respiratory therapists, for physical therapists, for everybody across the healthcare spectrum. And so it's very important to me to talk about that history and especially how things have been changing over the last couple of years with the pandemic. Right. And Dr. Farrington, in your experience, what have you noticed recently that in the last two years have made you more concerned? I think as Dr. Moses was referring to, it's our overall stress level in our healthcare workers. I mean, I come home and the stress headaches sometimes because the kids are so sick and the number of people there to actually take care of them, whether we're responding to a trauma in the emergency department or taking care of kids in our pediatric ICU, the number of people that are there, or sometimes there's new people who have never done this before because our more seasoned practitioners have left, I think that leaves stress on everyone. And I think it seemed to get better for a while, but with the COVID numbers going back up between the holidays, I think stress levels have increased again. So I think we've gone through a couple cycles, but I think sometimes at the end of those cycles, people are just so exhausted that I've seen a lot of people leaving the workforce or some of our seasoned practitioners are retiring early because they're like, I'm to the point that I can retire and I'm exhausted. I'm really glad that you brought that point up, Dr. Farrington, about people leaving. And I think that's one of the things that we talk about when we talk about moral distress as being one of the key factors that drives burnout. I think that's kind of what we're seeing on a really epic proportion. And it's actually something that I've written about that the pandemic inside the pandemic that we are seeing in our profession in critical care is the attrition. There's a pandemic of attrition that is burnout from so many people. And I think that there, I don't know if you've seen this in your environment, I know I've seen it in mine, that it's not just a matter of stress, it's a matter of things being different than they were before in terms of what our constraints are. Like medicine is hard, critical care is hard, sick people being sick is stressful. And it's part of why we do our jobs is because we actually are very good at managing that stress. And I think that when I talk to people about what I do for a living, one of the first things they say is how do you do that job? And they were asking me that question before the pandemic. I'm guessing you've gotten that question a lot of times too. And I know obviously you're gonna get that question all the time, but we are, we who choose to work in critical care, we self-select for this. We can manage a lot of the stress, but what we're seeing now in the pandemic is that the constraints that we're operating in are so bizarre and so different from what our expectations were either coming in or as we've practiced for however long we've been practicing things like early on in the pandemic, the availability or non-availability of PPE. I mean, before 2020, the only time I put on an N95 mask was the rare occasion that I had a patient that- Tuberculosis. Active tuberculosis, exactly right. And as far as the other things, the gowns and the eye protection, one of the drivers that I saw, a lot of communication happened early on in early to mid 2020 about not using gowns for other things besides COVID because we were saving gowns. Those disposable yellow or blue gowns for COVID patients. And so all of a sudden, things like the hospital's policy about MRSA just kind of went away, because we weren't gonna theoretically kill anybody by an accidental MRSA contamination, but if God forbid, we contaminated somebody with COVID, we thought we were going around potentially killing people. And that change, the constraints and the limitations just so different. Did you guys see that at your institutions as well? We never had a restriction on the use of the gowns, but just the whole, like we were ordering masks and from wherever we could get a mask. And some of the masks we got, you had to tie like in three places and were really challenging to just keep on your face because the ones that went elastic around your ears, we just couldn't get from anywhere. I think the other thing that has added to the moral dilemma and moral stress that we're having now is many of our drug products or the plastic, the little vinyls on the vials or the glass vials that things come in are from China or other countries. And the amount of drug shortages we're having right now, just this like adding on to the whole stress of everything. We can't get fat emulsion. We're giving our adult patients fat emulsion only two days a week, because that's all the supply we get allocated. Our neonates, we are still giving it to them daily, but we have no potassium acetate whatsoever in our building, we can't get it. So we're kind of restricting. We have a very strict oral policy on replacing people whereas before, if somebody had a low mag or a low potassium, whatever the doctor wanted, they got, because it really didn't matter. If they had a central line, go for it, right? But now, unless their level is dangerously low, we're calling the provider and our providers have been incredibly good at pulling up that policy we made for them and ordering oral KFOS or KCL. But the shortages are making it even more challenging to take care of patients and trying to conserve what we have for the patients who need it the most, just adds another level of stress onto what we're doing every day. You're right. And I think one thing I will add on is there is stress. And as Dr. Moses highlighted that the burnout was already there. And now we are noticing that people are more vocal about it because previously no one cared about the individual burnout or the burnout of one subspecialty like emergency medicine or critical care, which was already at high risk of burnout based on what they were dealing with. But COVID brought that into the limelight that everyone now knows about it. And if you look at the recent article that was published at the burnout in ER and critical care is like at the highest level possible. So that's the stress part of it. And knowing that supplies were limited, you're running out of necessary medicines and equipments, but there is a moral component to it too, right? How do you provide care when there are opportunities that people can take care of and that they need to own part of the responsibility? It's not just on the healthcare professionals. So you have read articles about how do we keep the moral aspect of it and the professional aspect of it is vaccination, masking, social distancing. This is kind of the hard topic too. And I think we need to talk more about that, like our responsibilities outside the walls of the hospital where we need to be advocated, we need to fight the misinformation. So that's the moral distress part of it as well for healthcare professionals when your own family members don't believe in vaccination and you are leaving the ICU pronouncing someone dead. Families and lives that have been devastated, how do you justify that out to the community? So that's the moral injury that healthcare professionals are going through. I was just having- I'd just like to make a quick comment, sorry. I think when we talk about, I think outside of the institution is critically important and Ben takes care of adult patients, I take care of little people, but we have parents who come in who clearly were having a newborn and they're not vaccinated. They have no desire to be vaccinated but then now their child is critically ill and on a ventilator. We had a child just recently in with multi-inflammatory syndrome of COVID, so MIS-C, and the mom said, well, my child has never had COVID. And we said, well, we measured antibodies and your child has antibodies. And as we leave the room, the nurses are on the phone. The doctors here are just lying to me. They're telling me my child has had COVID and I know that's not true. Just dealing with families that won't accept reality is very challenging. And then when you have all these parents who come in with a child who has a disease in which they could have prevented, to keep your positive spirit and go in and treat them like you treat everyone else, I think it's part of that moral compass is you have to just go in with that positive attitude and say what you would normally say to any family, even though you wanna walk out of the room and go, well, I guess I can't say that. If you're talking Saturday Night Live here, you could say, Jane, you ignorant slut. But that's just, only the old people on the call here are gonna get my joke. But I think it's very frustrating when you have some families that come in, the child is ready for their booster and they're like, can we get our booster before we leave? Everybody in the family is vaccinated and they're in for something else. But we're saying that children don't have as bad of respiratory disease with COVID, but we're seeing an astronomical increase in type one diabetes and PERP appendix because of the inflammation that children are getting. So the parents come in and they say, well, children don't get respiratory disease. And I'm like, but you don't know all the other things we're seeing. And that's what's really not out there and education in the community is the increase in other diseases, specifically we're seeing from all the inflammation. I don't know what you're seeing there at UVA, but it can be very frustrating and having a positive face with a family who, we've had adult patients beg to be vaccinated as you're intubating them and it's too late. Yeah, I think one of the, like you hit on a wonderful point about how do you keep your composure when talking to people who have made choices that I wouldn't have made that put themselves and other people at risk. And I had this conversation with, actually one of my neighbors, who's an eighth grade teacher who is struggling with the now decrease in mandates for vaccination and masking and how to talk to students and their families about how to protect themselves. And I know that that's not in a clinical setting, but really it speaks to this. I said, most people understand the concept that if you drink alcohol and drive a car, you're putting yourself and other people at risk. And the best way to minimize that risk is to not drink and then drive. And that is something that actually has taken, I mean, there are still ads on television about don't drink and drive. Why are there still ads on television? Because people still do it. Because people, even people who know that it's a bad idea still do it. And every day that I work at the hospital, somebody comes in as a trauma patient from a drunk driver, right? The reality is that people still make bad choices even when they have information. And I'm not, I don't want it to accuse anybody of intentionally going out to try and harm people because I truly believe most folks, when given the choice between right and wrong, are gonna choose right. But there's such a misunderstanding, misperception of what it takes to keep themselves and other people safe and the ways in which our choices affect other people. So that, you know, that's how I described it to my teacher friend and maybe how she could catch the conversation with kids and their families. But when I go to the ICU and I have that patient who was the drunk driver, how do I talk to that person in the room? Well, usually I do my best to be the professional. You know, it's my job to that person, my responsibility as a critical care physician is still to try to help them get better. And I would never want to affect that relationship inside the ICU by taking out my own emotional turmoil on them. But the reality is after two years of the pandemic, people are having a really hard time keeping their composure because- You have to keep your compassion for that patient and it's hard sometimes. It's so hard. It's so hard. You're right. And you said it well, Dr. Moses, that our professionalism dictates that and we will do our best when it's an individual patient and we will take care of that patient irrespective of all the decisions they have made that brought them. We do the same for patients with diseases that are kind of as a result of some bad decisions, right? Like cirrhosis or alcohol disease and chronic smoking and lung cancer. So this is not different. It is actually, it's the polarization that has happened in this country and almost every other country as well where the misinformation through different platform has taken over. And I'll add one more thing. The Society of Critical Care Medicine is international. They'll be listeners from part of the world. They don't have access to vaccine. And it's a shame that we in this country have surplus and we are not able to convince the population that has access to it to take the vaccine whereas people are dying from a preventable potential disease at this point. And it's free. We're not even charging for the vaccine. It'd be different if people had to pay to get it. I can say that at our institution, we had vaccine clinics here at the hospital. Every weekend, we actually took over a movie theater when all the movie theaters were closed. The owner of the movie theater allowed us to set up in his theater. That way people, there was plenty of parking. People had a place to wait after their 30 minutes after their vaccine, 15 or 30 minutes. And it was amazing how many people came through and their attitude. We saw what looked like large numbers, but we're still only 70% of Wilmington area vaccinated. And the rural communities near us are worse. And that's where we're seeing. I think you hit the nail on the head. It's the misinformation, which is damaging our healthcare efforts. My neighbor next door has an immunosuppressive disease. She's on an immunomodulator. And I was talking to her husband one day and he said, well, she can't get the vaccine. And I said, well, I'm not certain who told you that. I said, she may not have the same response to the vaccine. But he told me she could not get it and they should not get it. I said, well, I said, I can just tell you my understanding. And I tried not to be pushy. And that's what we have to do as healthcare providers. I just said, actually, she's the first person who should get a vaccine. And I'm sure that when the time comes, they're gonna be giving booster doses earlier to these patients getting those types of medications, which ended up being the case. And I said, and you and your two sons should definitely get the vaccine because the last thing you want to do is bring it home to her and have her get sick. And that's all I said. I kind of stopped. I said, if you have any other questions, I said, I'm dealing with this every day. Please come next door and ask me. But if you're pushy and push your opinions on someone, they're not gonna get a vaccine. But someone in the healthcare field gave them this information, which was scary to me that it sounded like one of their healthcare providers, whether it be their primary care provider or whoever was giving her that immunosuppressive therapy told them that. And that's what's hard with me to deal with when we're out in our communities is how do you deal with your neighbors, your loved ones, your colleagues who have been given misinformation from someone they trust. And so now they feel like that's true information. And so you have to just generally give them correct information and then offer to give them more. And unfortunately they chose not to get the vaccine because of this. And the whole family got COVID and she was very sick. So it's hard to watch people go through stuff when someone who was supposed to be a healthcare advocate pushed, as you were saying, gave their belief to these people. And so now they're not immunized because they were given incorrect information because of the personal feelings of that person. So the contrast between a trusted friend and a healthcare professional who is giving best evidence is enormous. And it's something that, I mean, we all see this. We've seen this all the time. But how much do I use guidelines in my practice? It's actually quite a lot. Society of Critical Care Medicine helps us in a lot of ways. In my conversations, say for example, we're in the ICU and I have learners there. I have students and residents and fellows there. And we're talking about best practices. So often I can reach back and say, okay, well, if you look at the SCCM guidelines, most obvious first example would be the surviving sepsis guidelines, right? And we update the guidelines with data periodically. And we use these guidelines to have a framework. And we can say, this is the best practice based on a lot of data. And this is a consensus guideline. And so we're able to speak with a common language when we're talking to each other using things like SCCM guidelines. One of the ones that I talk about a fair bit that was, you know, recent, well, relatively recent, the ABCD bundle for ICU liberation. And kind of bringing it back to the moral distress part of this, not just the vaccine hesitancy that's led to so much disease, but actually the things that we were starting to do routinely to get people out of the ICU, such a big part of it was family engagement. And that disappeared. And we've taken a step, you know, two decades back in the way that we take care of people. People are isolated all the time. And so not only are we not doing what we think is the best medicine, but we can't even have families at the bedside. We're getting them up to ambulate and having the team of people that would help that person ambulate, even while they were still on a ventilator. We had our lung transplant patients who were still on a ventilator. Somebody's pushing the ventilator. Somebody's making sure all the cords and lines are appropriate. Patients were up and walking. And now if they have COVID, they're in their room and a big group of people cannot go in there. So I think we've really lost that ambulation piece. And I think the isolationism is increasing our perhaps delirium. It's harder to get that person on a strict jade white cycle when, you know, normally we would go in and turn on the lights and then we would make them sleep at night. But now the person's in there doing a lot of this stuff by themselves because all the pumps and stuff are outside the door and the nurses are trying to go in as least as possible because that uses up PPE. I think all the things that we, I agree with you, Dr. Moses, those advances we made in decreasing delirium because we're improving their day light cycles and getting them up ambulating earlier and having that interaction with their family. And for us, the parents taking care of their primary care, you know, parents are in there doing the changing their diapers and feeding them like they were at home. So that child feels that connection to their parents. We lost all of that when we had a patient who was in isolation and we at Children's Hospital actually had a different visitation policy than the rest of the hospital. We were allowing two people to come. They had to, obviously, they couldn't just come in and out all the time if the patient had COVID, but there were certain times like a new diabetic diagnosis that both parents had to be here for education. You couldn't just educate one parent and feel comfortable that that two-year-old was going to go home and get the right thing done because what if mom is gone and dad's the only one there? So they were allowing us to have both parents there for critical things like teaching. And that was a challenge. Dr. Farrington, please go ahead, Dr. Moses. I was going to ask, so that's a difference from before. One of the other big drivers for us of concern, and I was just thinking about this, the elective surgeries and the changes over the course of the last few years about when and under what circumstances people were going to the operating room, either people who already were in the hospital or people coming in from home and having operations, and how resource utilization changed. Because when you're talking about PPE is what made me think of that. Because so many people had either delays in indicated care because they were afraid of coming into the hospital. And that led to a great amount of distress on the part of even non-ICU physician providers and other members of the care team. You could be an oncologist taking care of somebody, but your patient that should have an operation has a delay of four or six weeks because they're not doing, quote unquote, elective surgeries, or your institution has gone to doing emergency surgeries only because of the availability of PPE or staff or beds because of COVID. And it just piles and piles on. And I don't know if you saw that at your institution or in Cleveland, but we definitely compounded, you used the term moral injury before. And I think that's a really, really important one for us to talk about. And to again, remind our viewers and listeners, the idea that repeated moral distress actually leads to an injury. I think a perfect example of that is parents weren't taking their kids to the doctor. It was remote access was difficult. And I would say something simple like our floor patients, maybe not an ICU patient who comes in with an appendicitis, we're probably a 90, 10 rule, 90% are non-perforated. They go in as laparoscopic, they're out and 10% were, are perfed. And they do a little bit worse depending on the severity of the perforation. They're in a little bit longer, but during the peak of the pandemic, I would say we were probably at the 80, 20 rule where 80% of our patients who came with appendicitis had a perforated appendix. And so the amount of antibiotics we use, not, so now we're not just using PPE, they didn't have COVID, but the reason they didn't seek care is that they didn't want to be sitting in a waiting room somewhere and get COVID. And we saw kids that were just so much sicker with perfed appendix, even though there's some association with post COVID inflammation, with maybe more appendicitis, but it was astounding how many perfed appendix we were seeing. And then the followup abscesses that, you know, the small percent of abscesses that you might get was there. The two example that you both gave actually, Dr. Farrington, for example, having two visitors policy at children's and allowing both sets of parents to be part of the team, essentially, you know, I've said this before that we need to treat adults with the same kindness that we offer to kids and their families. And it's a shame, it's truly a shame that what we do to adults in ICUs in the terms of caring, we care for them, but we don't ever care for the family unit, the way we do for kids, because we include parents of the kids as part of the the whole, whole unit. And I wish, as the, as the, the, the surges die down, and actually, actually at Cleveland Clinic, we have already expanded the visitors policy to already, and I think that should be the norm. And what Dr. Moses highlighted like the the lag at this point that we will face, going back to the full speed of engaging families is going to require active effort on part of everyone to be aware that we suddenly got used to not having families for two years. And that will require active effort to, to bring back that kind of care to the ICU. When we were talking previously about giving the same care to everyone, I think sometimes we see the opposite. We see those families who their child was in with COVID, and you know, and they're told if you come in, because obviously, the parents are positive, too, you won't be able to leave the hospital room. We had some parents that didn't even come at all to be with their children. And some of them were infants who were, you know, needed to be fed every three hours, because they're selfish, and they don't want to have to ruin their own little routine of having to be stuck in a hospital. And it was really hard when they came in to pick up their children, because the child was ready to go home to treat them with the same compassion, give them the same teaching, because you're like, you didn't care enough about your child to actually come in the hospital, because it was going to ruin, you know, your lifestyle. And that you say you see both sides of the coin. You see the families who are dying to be there. I mean, iPads are nice. We at the hospital bought a boatload of iPads to allow people in their room, because now it's going to be in a COVID room to communicate with family members. That's still not the same as having the family member there. But at least that was something people could do to reach out. But only if that family had an iPad or some type of access where they could communicate with the same information. You know, the one thing I will say, Dr. Farrington, like the background of those family members who are not able to come to their infant, they might be socioeconomic circumstances beyond their, their possibility. These are probably some of them have no transportation, the meal cards, food cards, but when you, you know, see them drive off in their BMW, and yeah, I think it's the 9010 rule. It was only a small 10% of those families who just didn't come in. I think the majority of our families were there and wanted to be there. And the ones that weren't, you're you are absolutely correct. It was a financial burden, maybe one or two of the parents no longer had a job because of COVID. Right, right. So there are so many that you knew for a fact could have been there. And it was very frustrating. Right, right, right. You know, as Dr. Moses had previously highlighted, and as you had previously alluded to that, at this juncture, where healthcare professionals are already going through the moral distress of everything else, I think we need to lend each other more grace and more kindness and more empathy within the units within the doctor nurses relationship and nurses and nursing student relationship and between pharmacists and as a team. I think that's one of the key takeaway for me has been in the last two years being a pandemic fellow. That's what we have been called here is like our training has been changed in ways that no one had ever imagined. And Dr. Moses actually highlighted this right in the beginning that we chose to be critical care physicians or nurses. And for us, this is our calling. And sure, we've been through a little bit more harm in the process of being more exposed to the disease when vaccination was not available. But at this point, I think, how do we keep the morale of the team high is the goal? How do we prevent doctors and nurses and everyone involved in this pandemic? How do we keep them from burnout, like accelerated, accelerated path to burnout? What can society do? What can society of critical care medicine do healthcare administration do for the professionals? I have an immediate thought on this. And it's it goes to the principles of diagnosing and treating disease. That the first thing that you have to do when you're trying to help somebody is acknowledge what the facts are. Right? You take a history, you do an exam, you collect a series of facts, and then you use those facts to to make a diagnosis and a treatment plan. And if we look at moral distress around the pandemic, as our disease, what are the facts? And are we are we dealing with facts and agreeing on the facts? Well, I think the first thing we have to do is agree that we are tired and this sucks. It's it's it we come from a culture of of putting our own well being second to the patients that we're taking care of all the time. And the reality is, this is such a big disease, that the burnout and the moral distress that we see during this pandemic, this is a disease that will kill medicine if we don't treat it. So part of that, to answer your question, going to the point of what our ability is, as a society of critical care medicine to help, well, let's let's start by acknowledging the facts. And it's it's peer to peer, it's it's you and me looking at each other at the middle of a day or the end of a day in the ICU and saying, you know what, this sucks, this is really hard, and I'm really tired, and acknowledging each other's pain that we're going through, and agreeing that it's okay to be really, really affected, that you don't have to go through the stressors that we're talking about that Dr. Farrington is talking about these incredibly stressful things that we see. It's, it's, it would be magical thinking, to say that we could go through these things and not be personally and permanently affected by it. So we have to, we have to acknowledge that we have two little things I think that can be used to really help. And sometimes it's something stupid, like, I like to bake, and sometimes I would just have a really bad day and coming home and baking something just kind of distress me. It's like in the spring, it's like coming home and pulling all the weeds in the, in the yard. It's like, you know, the frustration of getting the weeds out, but then it looks nice for a while. I think each person has to find what is their de-stressor. Whether it's listening to Amy Grant hymns in your car on the way home, because you're a spiritual person, and listening to that kind of music kind of makes you feel better. Is it finding a new hobby that you haven't had time for? But for me, every time I would bake something, and I would bring it into work, the smile on people's faces is that somebody like took the time to bring them something. And sometimes just a family bringing in we have this place near the hospital that has these glazed croissants, they're evil. I mean, you look at them and gain weight, you don't even have to eat one. But you know, just something simple, like bringing a treat to show your appreciation, I think meant a lot to the healthcare workers that are still there. So I think that's helpful is like little warm fuzzies, as we would call them growing up, something little to do for something. I have a colleague who she loves a diet sun drop, and she can't find it. So I went and bought a bunch and kept them in my office. And when she was having a bad day, I would just come and bring her one. And the smile on her face was just like, Oh, my God, you just made my whole day could be something little that you could do for people. And then I think as each individuals, you have to find what it is for you that you can do to de stress something as simple as we had four of us that would go one day a week to the wine sampler, it's a little place here in town, and they put in machines, so nobody had to touch anything. But we would just sit and enjoy we couldn't, the rule was you couldn't talk about work. And we would sit and enjoy a glass of wine and then go home. So to de stress yourself before you got home to your family, your kids. That way, when you got home, you had a positive frame of mind in which to deal with your new responsibilities of making dinner. Because all those responsibilities don't go away when you're having a really bad day, you come home and it's all still there. The laundry, the time to make dinner to put people to bed, whatever, is still there for when you get home. So that's what you need to do is find out how you can de stress your way on the way home and not taking out on your loved ones. That's right. And I think, you know, this is a topic that we will, we can talk and we should definitely talk for hours. But because we have limited time on this, I think what you had highlighted Dr. Farrington is individual responsibilities, right? And what we can do to help ourselves cope up with this. But I think I want to highlight to people who are in power of positions to make it easier for the individuals who are doing everything in their power to do better, right? To make it easier for essential workers or healthcare workers who have done their part. I will continue to do that because this is our calling. But the responsibility should be shared by people in position to make life easier for everyone who will continue to do this, irrespective of the next pandemic and beyond. I do want to ask Dr. Moses and Dr. Farrington to kind of give words of advice to listeners and to anyone who's in position to power, what is your message as we try to wrap this up in limited time that we have? I'd say that the takeaways for me, and I've really enjoyed this conversation, Dr. Farrington, I'm really glad to have gotten to be here with you today. And I hope that our viewers and listeners get something out of this as well. One, I think that what I have to work on every day and what I think everybody should try to work on is being kind to ourselves. I have to be kind to myself. And I sometimes have to remind other people around me to be kind to themselves too. This, what we do is very hard. It's very important. It matters. And I thank you all for doing what you are doing and to be kind to yourself and acknowledge that what you're doing is really important. That's right. Thanks, Dr. Moses. Dr. Farrington. Yeah, I agree with Dr. Moses a hundredfold. We need to be kind to ourselves. We need to take care of our coworkers who are there. But I think for administrators, what they should hear, I think what was very frustrating for some people where I work is nurses were being offered twice pay. I mean, granted, you can't take care of a patient if you don't have a bedside nurse, but other professions such as, you know, the pharmacist, the physical therapist, the occupational therapist, the respiratory therapist, they didn't get offered extra pay. We're all still coming in and working that we were working overtime. If I worked overtime, I got my straight salary because pharmacist or salary, we get our straight pay. I think that adds stress to the moral dilemma because it makes you feel like you're less important than the other workers that are being offered twice pay. So for an administrator, I think before you go out and offer something like that, you need to think about should I offer less pay and offer it to everyone than to make the other professionals feel like we feel like this one group more than the rest. Now I'm 100% in agreement. We can't have a patient if there's not a bedside nurse, but it's still I heard a lot of people talking about how it wasn't fair that they got that pay and they weren't offering it to other groups. Even housekeeping, I mean, to me is almost as important because if you can't get the room clean, you can't get another patient in. So I think that's something administration should hear is when they make those decisions, they need to think about the implications it gives to the staff that are there working just as hard as everyone else. Right. And I'm glad that you highlighted Dr. Farrington, the concern of equity and inclusion when it comes to making these decisions. And sometimes, you know, these decisions are made at level that we are not privy to. Right. And I think an open line of communication is the best way to kind of help people understand why is someone getting more? And if you know that, maybe that will ease this moral dilemma and the stress that, oh, well, okay, makes sense for this reason, rather than just presuming what is happening. So equity, inclusion, the kindness message that Dr. Moses provided, it's so important. And I can't agree more. I do want to thank both of you for taking the time of a busy schedule during the pandemic to talk. And with that, I think we will take some questions as the time allows. So thank you both. Thank you very much for including us. We appreciate it. Thanks. Thank you so much. Thanks.

moral distress

pandemic

healthcare professionals

shortage of nurses

moral dilemma

burnout

support

equity